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International Journal of Transgender Health logoLink to International Journal of Transgender Health
. 2021 May 4;24(1):99–107. doi: 10.1080/26895269.2021.1919277

The impact of living with transfeminine vocal gender dysphoria: Health utility outcomes assessment

Brian Nuyen a,✉, Cherian Kandathil b, Daniella McDonald c, James Thomas d, Sam P Most b
PMCID: PMC9879186  PMID: 36713148

Abstract

Background: The voice signals a tremendous amount of gender cues. Transfeminine individuals report debilitating quality-of-life deficits as a result of their vocal gender dysphoria.Aims: We aimed to quantify the potential impact of this dysphoria experienced with quality-adjusted life years (QALYs), as well as associated treatments, through validated health utility measures.

Methods: Peri-operative phonometric audio recordings of a consented transfeminine patient volunteer with a history of vocal gender dysphoria aided in the description of two transfeminine health states, pre- and post-vocal feminization gender dysphoria; monocular and binocular blindness were health state controls. Survey responses from general population adults rate these four health states via visual analogue scale (VAS), standard gamble (SG), and time tradeoff (TTO).

Results: Survey respondents totaled 206 with a mean age of 35.8 years. Through VAS measures, these general adult respondents on average perceived a year of life with transfeminine vocal gender dysphoria as approximately three-quarters of a life-year of perfect health. Respondents also on average would have risked a 15%–20% chance of death on SG analysis and would have sacrificed 10 years of their remaining life on TTO measures to cure the condition. The QALY scores for the post-gender affirming treatments for vocal gender dysphoria (+0.09 VAS, p < 0.01) were significantly higher compared to the pretreatment state. There were no differences in the severity of these QALY scores by survey respondent’s political affiliation or gender identity.

Conclusions: To our knowledge, this study is the first to quantify how the general population perceives the health burden of vocal gender dysphoria experienced by transfeminine patients. Feminization treatments including voice therapy with feminization laryngoplasty appear to significantly increase health utility scores.

Keywords: Gender dysphoria, health utility, transfeminine, transgender, voice

Introduction

The voice is a critical component of both our identity and expression (Belin et al., 2004, 2011; Schweinberger et al., 2014). Among many dimensions of information, the voice signals a tremendous amount of gender cues (Bachorowski & Owren, 1999; Scherer, 1986). This can be problematic for people with gender dysphoria. This dysphoria as well as its compound interactions with malignant psychosocial and socioeconomic systems are known to lead to adverse health outcomes (Bockting et al., 2016; White Hughto et al., 2015; Whitlock et al., 2019).

Transfeminine individuals, or transgender people assigned male at birth but identify with femininity, report debilitating quality-of-life deficits as a result of their gender dysphoria (Bockting et al., 2016; Knudson et al., 2010; White Hughto et al., 2015, Whitlock et al., 2019). Given the gender information communicated by the voice, it is not surprising that transfeminine vocal gender dysphoria can arise from discrepant communication in vocal gender identity (Hancock, 2018) with dire social and health consequences (Timmins et al., 2017). This may be addressed with feminizing therapies for the voice.

Vocal feminization may include multimodal treatments, including voice therapy and/or a breadth of varied types of phonosurgeries (Nolan et al., 2019; Song & Jiang, 2017). Some of the most of the effective and feminizing phonosurgical interventions involve shortening the vocal folds (Song & Jiang, 2017). Such interventions include feminization laryngoplasty, a phonosurgical procedure involving the removal of the anterior thyroid cartilage, collapsing the diameter of the larynx while shortening and tensing the vocal folds to raise pitch, as well as fixing the thyroid cartilage to the hyoid bone to feminize the resonance (Thomas & MacMillan, 2013). No prior studies have examined the health utility of vocal gender dysphoria and treatments thereof.

Health utilities are values that represent strength of preferences for specific health-related outcomes. Utility scores are typically quantified using the visual analog scale (VAS), time tradeoff (TTO), and standard gamble (SG) measures (Drummond et al., 2005; Torrance, 1986). These outcome measures have been previously applied to an examination of general dysphonia (DeVore et al., 2020; Naunheim et al., 2020), but have not yet been used to investigate vocal gender dysphoria. Health utility scores are often reported as quality-adjusted life years (QALYs), as both a measure of quality and quantity of life lived. Critically, these data are often used in cost-utility analyses of health care interventions from a society resource allocation, important for publically-managed health care mechanisms (Drummond et al., 2005; Torrance, 1986).

In this study, we aimed to quantify the impact of vocal gender dysphoria through quality-adjusted life years (QALYs) experienced by transfeminine patients, as well as associated treatments, through validated health state utility measures. These data may better inform publically-managed health care mechanisms for transfeminine voice treatments.

Methods

Survey construction: Patient volunteer and health utility measurements

Upon Institutional Review Board approval of study design, recruitment for a transfeminine patient volunteer was conducted at the vocal gender dysphoria clinic of our coauthor (J.T.). All patient volunteers in consideration were managed per transgender voice and communication treatment guidelines per World Professional Association for Transgender Health (WPATH, 2016), had pretreatment/pre-operative and post-treatment/post-operative phonometrics, underwent vocal feminization which included feminization laryngoplasty with perioperative voice therapy by a speech-language pathologist. Voice therapy included conversation therapy training, nonverbal communication strategies, and resonant voice therapy. Perioperative phonometrics included standardized speaking passages (“Long ago, men found it easier to travel on water than on land. They needed a cleared path or road when traveling on land, but on water, a log of wood or any large object that would float became a man’s boat”; see ESupplement). Based on previously-published data about feminization laryngoplasty outcomes, a volunteer with median phonometric outcomes observed (Thomas & MacMillan, 2013) was selected for use of peri-treatment speaking passages for this study; the volunteer’s pronouns were she/her/hers.

Based on qualitative and quantitative reports (Dacakis et al., 2017; Davies et al., 2015; Hancock, 2018; Hancock et al., 2011; Nolan et al., 2019; Oates & Dacakis, 2015; Song & Jiang, 2017; Verbeek et al., 2020), and in the typical health utility state fashion (Morimoto & Fukui, 2002) descriptions sketching the state of pretreatment transfeminine vocal gender dysphoria were created. This health state, as well as the post-treatment transfeminine health state, and a monocular and binocular blindness control, were used for the survey (ESupplement).

For each of these health states, the health utility scores were measured using VAS, SG, and TTO measures. Each measure generates a fraction of a quality-adjusted life year (QALY), a value that signifies disease burden whereupon one QALY equates to one year in perfect health.

The VAS used in health utility studies is a sliding scale continuum with anchors representing worst possible health (death, i.e. score 0) and best possible health (perfect health, i.e. score 100) on opposing ends, with respondents asked to rate health state (Parkin & Devlin, 2006). The VAS would then generate a value x, whereupon x/100 would represent the health utility of that heath state queried as a QALY.

The SG involves presenting individuals with a choice between two options: the health state queried that is certain and unchangeable for duration of life and a gamble with one ideal (perfect health) and one worst-case (death) outcome possible (Lenert et al., 1998). Respondents are then asked what probability of the ideal outcome would make them indifferent between remaining in the health state surveyed for certain or choosing death. This probability would then represent the QALY generated by the SG. In this study, participants were first presented a specific risk of death starting at 0%, which if accepted, progressed to serially-increased risks that was uptitrated by 5% until the risk of death was 100%, in an “bottom-up” manner. Compared to other elicitation methods, a “bottom-up” manner is a well-validated elicitation method suggested to have more reduced variability between subjects (Lenert et al., 1998).

The TTO asks subjects to consider the life-years they would be willing to sacrifice to avoid the health state queried in favor for perfect health, represented by y (Arnesen & Trommald, 2005). Based on reported average of hormone therapy initiation for transfeminine patients at 31 years (Beckwith et al., 2017), the 2015 United States Transgender Survey’s findings that the majority of transgender patients started gender-affirmation-related treatments between 18 and 44 years (James et al., 2016), and approximate average life expectancy in the US of 78 years, 47 years was chosen as the maximum number of time that one can choose to live without trading off years. In this study, y was uptitrated from a “bottom-up” fashion similar to the SG measure. The QALY was then calculated as (47 – y)/47.

Survey distribution among general population respondents

After survey construction with the four health states each with VAS, SG, and TTO outcome measures, the survey was dispensed through the Qualtrics platform. This platform was used as part of a greater survey project examining health economic preferences in treatment for gender dysphoria. Each survey was then distributed to a requested, nonrepeated sample size range of 200–210 participants from within the Qualtrics survey corporation’s participant database (≥18 years). This database recruited by Qualtrics survey corporation is a broad societal cross-section of thousands of general population individuals from the United States who belong to a general population Qualtrics survey cohort who have expressed willingness and availability to complete surveys. Participants provided electronically-affirmed informed consent prior to participation, were unaware of the purpose of the study, did not take the survey more than once, and were reimbursed for responses. The participants reimbursed through the third-party Qualtrics survey corporation and thus retained anonymity to the researcher authors. Any survey respondents rating binocular blindness as having higher health utility than monocular blindness by VAS, SG, and/or TTO was removed from analysis, given the well-established health utility difference between monocular and binocular blindness (Morimoto & Fukui, 2002). Additionally, incomplete surveys, surveys with identical responses across all questions, or surveys completed in less than five minutes, were removed. These exclusion criteria were established a priori as mechanisms to safeguard against surveys that were completed without sufficient consideration of the health economic cognitive tasks at hand. If a participant’s survey was excluded from given aformentioned a priori exclusion criteria, Qualtrics then automatically distributed the survey to another new, nonrepeated participant. In this process, a total of 288 surveys were distributed.

The age of respondents was defined in full years at the time of survey. Ethnicity was defined as White/Caucasian, Black/Afro-American, Hispanic/Latino, Asian, or other. Educational level was dichotomized as high school vs. no high school for statistical analysis. Annual income was graded as < $25,000, $25,000–$50,000, $50,000–$75,000, $75,000–$100,000, $100,000–$125,000, $125,000–$150,000, and >$150,000. Political affiliation was recorded as Democrat, Republican, or other. Having had personally gender-affirming medical and/or surgical treatments or having friends/family who have had gender-affirming medical and/or surgical treatments were dichotomized as yes vs. no.

Statistical analysis

The means and standard deviation of utility scores were calculated. After assessment for normality using the Shapiro-Wilk test, one-way analysis of variance with post-hoc Tukey significance with Bonferroni correction for multiple comparisons was used to detect any significant differences among the health utility scores by outcome measure among the health states. Multivariate regression analyses were used to predict the value of the responses based on the value of the respondents’ characteristics. The results were judged by a p-value and a coefficient of determination (R2). A p-value ≤ 0.05 was considered significant. All the analyses were carried out using Stata/IC Statistical Software: Release 15 (StataCorp LP, College Station, TX, USA).

Results

Table 1 describes the 206 participants with completed surveys that met aforementioned criteria. Respondents’ average age was 35.8 years (standard deviation 11.9). Most participants identified as white, straight/heterosexual, and reported completing high school. The majority of our respondents identified as cis-gender. The largest percentage of represented annual income reported was within the $10,000–$50,000 range. The political affiliations were largely split evenly between Democrat and Republican, without other or third-party affiliation reported. The majority did not personally have or know personally friends/family who have had gender-affirming medical and/or surgical treatments.

Table 1.

The sociodemographic characteristics of our respondents.

Sociodemographic characteristics  
Age, mean (SD) 35.8 years (11.9)
Race, n (%)  
 Asian/South/Southeast Asian 11(5.3)
 Black/African American 25(12.1)
 Caucasian/White 151 (73.3)
 Latino/a/Chicano/a/Hispanic 10(4.9)
 Native Hawaiian/Pacific Islander 2(1.0)
 Native American/Native Alaskan 2(1.0)
 Other 2(2.4)
Gender identity, n(%)  
 Man, assigned male at birth ("cis man") 93(45.2)
 Woman, assigned female at birth ("cis woman") 107(51.9)
 Transgender man (transmasculine, man assigned female at birth) 1(0.5)
 Transgender woman (transfeminine, woman assigned male at birth) 3(1.5)
 Nonbinary/genderqueer 1(0.5)
 Other 1(0.5)
Sexual orientation, n(%)  
 Straight/heterosexual 186(90.3)
 Lesbian/gay/homosexual 5(2.4)
 Bisexual 13(6.3)
 Other 2(1.0)
Income, n(%)  
 <$10,000 20(9.7)
 $10,000–$50,000 90(43.7)
 $50,000–$80,000 53(25.7)
 $80,000–$160,000 35(17.0)
 >$160,000 8(3.9)
Political affiliation, n (%)  
 Democrat 102(49.5)
 Republican 104(50.5)
 Other 0.0
Educational degree, n(%)  
 Trade/technical/vocational training 4(1.9)
 Some high school 5(2.4)
 High school graduate or equivalent 55(26.7)
 Associate degree 37(18.0)
 Some college credit 42(20.4)
 Bachelor’s degree 47(22.8)
 Master’s degree or doctorate 16(7.8)
Personal/family/friend history of gender-affirmation treatments, (n)%  
 Yes 27(13.1)
 No 179(86.9)
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Table 2 records the mean and standard deviation of the health utility scores. Per measure, each health state demonstrated a statistically-significant difference from the other health states. Binocular blindness had the lowest health utility across all measures. The average health utilities for the health state of post-gender affirming treatment for transfeminine vocal gender dysphoria were highest among the other health states, including the pretreatment state.

Table 2.

Health utility scores of characterized health states by utility measure.

  QALYs, Mean (SD)
  
Measure Monocular blindness Binocular blindness Pretreatment transfeminine vocal gender dysphoria Post-treatment transfeminine vocal gender dysphoria p value
VAS 0.61 (0.17) 0.39 (0.17) 0.76 (0.21) 0.85 (0.19) <0.001
SG 0.79 (0.20) 0.69 (0.25) 0.83 (0.20) 0.87 (0.19) <0.001
TTO 0.77 (0.19) 0.64 (0.27) 0.81 (0.18) 0.85 (0.18) <0.001
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QALY = quality-adjusted life year; SD = standard deviation; VAS = Visual Analog Scale; SG = standard gamble; TTO = time tradeoff; p value reflects the one-way ANOVA comparing the four health states’ VAS values to each other, four health states’ SG values to each other, and four health states’ TTO values to each other.

Table 3 documents the post-hoc comparisons with Bonferroni correction among health states. Across the three health utility measures, health utility was rated poorer for binocular blindness than monocular blindness. In the VAS measure, health utility was rated better for pretreatment transfeminine vocal gender dysphoria compared to monocular blindness. However, in the SG and TTO measures, health utilities between pretreatment transfeminine vocal gender dysphoria and monocular blindness were comparable. Across all the utility measures, health utility was rated poorer for monocular blindness compared to post-treatment transfeminine vocal gender dysphoria. Across all utility measures, utilities for binocular blindness were rated poorer compared to pre- and to post-treatment transfeminine vocal gender dysphoria. In the VAS measure, health utility was rated better for post-treatment transfeminine vocal gender dysphoria compared to pretreatment. However, in the SG and TTO measures, health utilities between pretreatment and post-treatment transfeminine vocal gender dysphoria and monocular blindness were comparable.

Table 3.

Health state comparisons by health utilities.

Health utility comparison QALY mean difference 95% Confidence interval Tukey HSD p value Bonferroni p value
Monocular vs. Binocular blindness  
 VAS –0.21 –0.25, −0.19 <0.01 <0.01
 SG –0.10 –0.14, −0.06 <0.01 <0.01
 TTO –0.13 –0.18, −0.09 <0.01 <0.01
Monocular blindness vs. Pre-VF  
 VAS +0.15 +0.12, +0.19 <0.01 <0.01
 SG +0.03 –0.01, +0.07 0.50 0.15
TTO +0.04 +0.00, +0.08 0.15 0.07
Monocular blindness vs. Post-VF  
 VAS +0.24 +0.21, +0.28 <0.01 <0.01
 SG +0.08 +0.04, +0.12 <0.01 <0.01
 TTO +0.08 +0.05, +0.12 <0.01 <0.01
Binocular blindness vs. Pre-VF  
 VAS +0.37 +0.33, +0.41 <0.01 <0.01
 SG +0.13 +0.09, +0.17 <0.01 <0.01
 TTO +0.17 +0.13, +0.22 <0.01 <0.01
Binocular blindness vs. Post-VF  
 VAS +0.46 +0.43, +0.50 <0.01 <0.01
 SG +0.18 +0.13, +0.22 <0.01 <0.01
 TTO +0.21 +0.17, +0.26 <0.01 <0.01
Pretreatment vs. Post-VF  
 VAS +0.09 +0.05,+0.13 <0.01 <0.01
 SG +0.05 +0.01,+0.07 0.11 0.05
 TTO +0.04 +0.00, +0.08 0.22 0.05
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VAS = Visual Analog Scale; SG = standard gamble; TTO = time tradeoff; Pre-VF = pretreatment transfeminine vocal gender dysphoria; Post-VF = post-treatment transfeminine vocal gender dysphoria.

Further, none of sociodemographic characteristics significantly predicted a differential response to the vocal gender dysphoria health utility measures.

Discussion

To our knowledge, this is the first study using health utility measures to examine and quantify the general public perception of the burden of transfeminine vocal gender dysphoria. These findings have generated quality-adjusted life year data that highlight the severity of the burden of transfeminine vocal gender dysphoria as well as the impact associated treatments have on that burden. These data may be critical in arming future cost-effectiveness analyses for publically-funded health care mechanisms.

The VAS findings showed that respondents on average perceived a year of life with transfeminine vocal gender dysphoria as approximately three-quarters of a life-year of perfect health. Furthermore, on average through the SG measures, our cohort would risk a 15%–20% chance of death to treat their transfeminine vocal gender dysphoria; through the TTO exercise, this cohort would sacrifice 10 years of their remaining life to treat the condition as well. These findings for pretreatment transfeminine vocal gender dysphoria were not dissimilar to the SG- and TTO-elicited health utility estimates for monocular blindness, underscoring the perceived gravity of this condition. The findings in our sample could not be attributed to our respondents’ sociodemographics, including their gender identity, sexual orientation, political affiliation, or their personal/family history of exposure to gender affirmation treatments.

Of the limited studies in the literature, most have examined the transfeminine and provider perspective on vocal gender dysphoria, including longitudinal and cross-sectional health as well as quality-of-life data related to vocal gender dysphoria and feminizing treatment (Nolan et al., 2019; Song & Jiang, 2017). Vocal feminization treatments including voice therapy and/or phonosurgery as a means to obtain congruence in expression and perception have been suggested to improve patient quality of life and improve psychosocial functioning ( Dacakis et al., 2017; Davies et al., 2015; Hancock et al., 2011; Oates & Dacakis, 2015). Along these lines, qualitative research on transfeminine individuals’ perspectives feature themes of experienced negative societal response to “passing” vocally as female, with significant barriers to social integration and function (Davies et al., 2015). Gender affirming care overall has also been documented as a protective factor against day-to-day mental and physical risks common to the transfeminine communities (Lenning & Buist, 2013; Wilson et al., 2015). Thus the health utilities encountered in this study associated with pretreatment vocal gender dysphoria, as well as the increase in health utility noted with vocal feminization treatment, appear to align with prior literature.

The strengths of this study include the use of peri-operative phonometric audio recordings to more clearly illustrate to our surveyed respondents the utility of the health states queried. Use of recordings has been used in a recent health utility assessment of dysphonia (DeVore et al., 2020). Other studies have generated utility values for laryngological pathology, including laryngeal cancer (Hamilton et al., 2016; 2018), but have not used audio recordings to exemplify disease burden as part of their methodology. Additionally, our elicitation of respondent sociodemographics including political affiliation allowed for us to examine for possible effect modifiers influencing determination of health utility. Lastly, use of well-validated QALY measurement tools such as the VAS, SG, and TTO strengthened these studies findings. Standard gamble and TTO are consistent with expected utility theory and rational individual behavior principles (Torrance et al., 1995). The VAS is based on psychometric theory and lauded for its simplicity (Parkin & Devlin, 2006). A review of utilities across almost a thousand health states found a strong tendency for VAS to yield the lowest, TTO the middle, and SG the highest utility values for the same health states, consistent with our findings here as well (Morimoto & Fukui, 2002).

The current study design bears important features to consider. A web-based survey with required audiovisual interpretation and English literacy carries with it recruitment bias. Our cohort was prevalently White/Caucasian, straight/heterosexual, and cis-gender; alternative sampling would likely have potentially affected responses. Of note, the demographic data of survey respondents that were excluded given previously-determined exclusion criteria (e.g. having rated binocular blindness as “better health” than monocular blindness) were not available in this study. Further, while transgender health care is politicized (Cahill & Makadon, 2017; Feldman et al., 2016; James et al., 2016), political affiliation was not seen to potentiate survey response. Furthermore, to reduce survey fatigue and limit survey-related recall bias, this study was designed and funded to examine a single transfeminine patient’s perioperative media, selected by our study authors to reflect both a satisfactory and median vocal feminization treatment experience (Thomas & MacMillan, 2013). It is important to note that despite the Delphi method leading to the choice of a volunteer with typical vocal feminization treatment experience, selection bias in the use of a single volunteer and associated limitation in generalizability must be acknowledged. Furthermore, given the real intersectionalities of our patients’ experiences, future studies examining the responses to perioperative media belong to diverse transfeminine patients with diverse treatments, including voice therapy and varieties of other types of vocal feminization surgeries (Nolan et al., 2019; Song & Jiang, 2017) with varied treatment outcomes would be particularly illustrative.

Our examination of the health utilities of transfeminine patients cannot be done without consideration of the oppressive systems through which transgender, nonbinary, and gender-nonconforming people (TNG) patients must navigate. Inordinate disparity predominates in a variety of critical life dimensions for many of our TNG patients, including differential access to housing, employment, legal protection, and medical care (James et al., 2016). Even the research on TNG health outcomes has faced significant barriers, with censored funding and the under-representation of TNG-identified scientists and researchers (Cahill & Makadon, 2017; Feldman et al., 2016). Therefore this study’s design carries inherent complications of the direct measurement of QALYs for this condition. Text descriptions and audio recordings in this study, typical of similar studies (e.g. DeVore et al., 2020) also utilizing validated VAS, SG, and TTO tools to directly capture QALY data, may not fully impress upon our general population respondents the malignant social determinants of health that TNG patients experience. Based on information processing research (Miller, 1956), the cognitive load associated with health utility exercises demands a limit on description attributes. Despite the severity in the results of utility measurements in this study, these sociopolitical considerations may risk an underestimation in our study’s health utility measurements.

Future opportunities to advance research remain. Assessments of health utility preferences in general can be performed by either patients or by the public, as was done in this study. The advantage in researching patient preferences is that the patients themselves are those who experience the burden of that disease. The advantage in researching public preferences is that in publically-funded healthcare systems, it is society’s resources that are being apportioned for disease severity assessments and associated treatments in a theoretically resource-limited setting. Views of the general population carry thus associated pertinent weight. Importantly, health utility measurements collected from transfeminine patients’ vocal health experiences are lacking; comparative measurements to elicitations from the general population would be illuminating. Transmasculine and gender-nonconforming health utility studies remain to be investigated, including transmasculine vocal gender dysphoria and treatments thereof. Additionally, other gender-affirming treatments for TNG patients are also deserving of further investigation.

Conclusion

In this study, transfeminine vocal gender dysphoria was perceived to have similar severity in health burden compared to monocular blindness. On average our cohort would risk a 15%–20% chance of death to treat their transfeminine vocal gender dysphoria; this cohort would sacrifice 10 years of their remaining life to treat the condition as well. Gender-affirming treatments including voice therapy and feminization laryngoplasty in certain health utility exercises appear to significantly increase perceived health. These data provide quantitative perspectives on the public perception of the disease burden associated with transfeminine vocal gender dysphoria and may be used for future cost-effectiveness research.

Disclosure statement

None to declare.

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